Pain Management Techniques to Help Conquer Back and Neck Pain

Procedures - Spinal Pumps and Stimulators

Intradiscal Electrothermoplasty (IDET) is an unproven minor procedure
used to treat low back pain. Back pain and sciatica can be caused by degenerative
disc disease, which may include disc bulging or herniation. These conditions
can cause nerve impingement, inflammation, and pain. During IDET and under x-ray
guidance, a needle is inserted into the affected disc. A special wire is then
threaded through the needle into the disc. After the wire is properly positioned,
it is heated. The goal of the procedure is to destroy the small nerve fibers
that have invaded the degenerated disc. IDET causes the annulus (disc wall)
to partially melt. This is turn triggers the body to grow new protein fibers
to reinforce the annulus.

Radiofrequency Discal Nucleoplasty is similar to IDET. It is a newer
procedure. A needle is inserted into the disc. Instead of a heating wire, a
special radiofrequency probe is inserted through the needle into the disc. The
probe generates a highly focused plasma field with enough energy to break up
the molecular bonds of the gel in the nucleus essentially vaporizing some of
the nucleus. The result is that 10-20% of the nucleus is removed, which decompresses
the disc and reduces the pressure both on the disc and the surrounding nerve
roots. This technique may be more beneficial for sciatic-type pain than IDET,
since nucleoplasty can actually reduce the disc bulge pressing on the nerve
root. The high-energy plasma field is actually generated at relatively low temperatures
minimizing the danger to surrounding tissues.

 Pumps and Stimulators

Patient-Controlled Analgesia (PCA) is used to treat post-operative pain.
The device is equipped with a pump that is attached to the patient's intravenous
line (IV). It is programmed to dispense the correct dose of pain-relieving medication
directly into the bloodstream. The patient is given control over pain by operating
the PCA with a hand-held push-button mechanism. Once past the acute pain stage,
the patient is switched to oral medication. The doses administered by PCA are
smaller and available more frequently. Pain relief is consistent. This helps
to prevent sleepiness and weakness allowing the patient to ambulate sooner.
It has been proven that PCA reduces the overall amount of medication needed
to control pain.

Spinal Pumps are called intrathecal (intra-thee-cal) spinal pumps. Intrathecal
refers to the fluid containing space that surrounds the spinal cord. The benefit
of administering pain relieving medication through a spinal pump is that medications
taken orally are diffused throughout the entire body. A spinal pump delivers
pain-relieving medication precisely where it is needed. This treatment is considered
after standard conservative treatments have been ineffective or have caused
intolerable side effects.

The pump is surgically implanted beneath the skin of the patient's abdomen.
A catheter is run to the level of the spine from where pain is transmitted.
Medication is pumped directly into the spinal fluid allowing for a much more
potent effect on the spinal cord. This drastically cuts down on the amount of
medication needed and provides better pain relief with fewer side effects. The
pump is refilled every 1-3 months by inserting a needle through the skin and
into a diaphragm on the surface of the pump. Several different medications can
be administered this way. Since the system is beneath the skin, the risk of
infection is minimized and the patient can be fully mobile and active.

Spinal Stimulators. Instead of medication to relieve pain, spinal stimulators
use electrical pulses on the surface of the spinal cord to reduce pain. The
stimulators are similar to pumps in that they are surgically implanted beneath
the skin but differ in that electrical signals are used to ease pain. Electrical
signals are passed through the tip of the catheter at the precise location near
the involved segment of the spinal cord. The result is a tingling over the painful
area, which eases pain. Current theory is that the electrical current input
alters the spine's processing of the pain so that the patient's pain is reduced.
The patient is able to control the stimulator by holding a magnetic pulsing
device over the skin on top of the implanted generator disk. The stimulator
appears to be effective for patients with back and leg pain that spinal surgery
did not relieve. There is data that shows that these patients will do better
with the placement of a stimulator than they will with repeat surgery.

Conclusion
As we learn about neuroplasticity, we have learned that good pain management
starts with prevention. When possible, physicians should strive to reduce the
intensity and duration of acute pain. When pain does persist, then a multidisciplinary
approach is often most effective. In severe cases, when pain does not respond
to usual treatments, then the more invasive techniques such as nerve blocks,
spinal pumps, and spinal stimulators should be considered. It is not always
possible to cure the cause of pain - but it is usually possible to reduce pain
and suffering.

This article is an excerpt from Dr. Stewart G. Eidelson's book, Advanced
Technologies to Treat Neck and Back Pain, A Patient's Guide (March 2005).

Dr. Richeimer, in his article, "Pain Management Techniques to Help Conquer Back
and Neck Pain," discusses an overview of the most common types of pain experienced
by patients with spinal conditions and a variety of non-surgical treatment alternatives.
This article is important because it provides easy to understand definitions for
the lay person and rightly demonstrates that many treatment options are available
for most degenerative spinal conditions. It is important to note that some of
the more recently described treatment options such as nucleoplasty and IDET remain
controversial because the scientific data supporting their benefit is sparse.
The foundation of an optimal comprehensive pain management program begins with
an accurate understanding of the source of the pain. This can only come from consultation
with a qualified specialist in spinal medicine. An accurate diagnosis serves as
the basis for discussing treatment options to address the spinal condition.

Except for complaint of headache, spinal pain is the most prevalent complaint
noted in physician offices. Fifty- to eighty-percent of all people will be impaired
by back pain of varying degrees at some point during their lives. It is extremely
timely and important that information regarding the available treatments for chronic
spinal pain be available for those seeking to understand the approaches to treatment.
Doctor Richeimer presents a logical and understandable review of some of the available
treatments. His presentation takes the approach of understanding the role of identifying
the structure(s) generating the pain and designing treatments to address the involved
structure(s). Some of these interventions are more well investigated than others
and some have become common based on extensive experience. Doctor Richeimer is
careful to comment on where these treatments are in regard to scientific acceptance.